Is it possible to forecast medical treatment and costs using big data and predictive models? How does a big data approach compare to conventional methods?
The foundation for these questions was the beginning of a 10-year journey, a quest to validate existing methods and determine if a better solution might exist to answer the problem of forecasting medical care for care coordination and claim settle settlements.
How did we get where we are today?
If you were around, flashback to the disability rights movement of the 1980’s, following the passage of the Rehabilitation Act of 1973, when activists lobbied hard for people with disabilities to have access to public transportation and public education. After decades of campaigning, the Americans with Disabilities Act (ADA) was passed in 1990 providing equal treatment and equal access of people with disabilities to employment and public accommodations. Under the ADA, businesses were mandated to provide reasonable accommodations to people with disabilities and full participation, inclusion and integration of people with disabilities. With this the emergence, the field of Life Care Planning evolved, entering the litigation space, to offer valuations of the injury costs to a person’s life and livelihood, in the event of an accident or injury causing disability. The Life Care Planning process was developed by Vocational Rehabilitation experts responsible for working with individuals with disabilities to restore and/ or maximize their functional capacity to perform independently both at home and at work. Life Care Planning methodology has become the standard for forecasting medical treatment over an individual’s lifetime and has been used extensively by both plaintiff and defense sides in litigation and jury trials to valuate medical damages, becoming the accepted standard for valuating medical costs.
Life Care Planners also found an opportunity to provide a solution to the dilemma of forecasting medical exposure for “Medicare Set Aside Arrangements” by streamlining and hybridizing the methodology to forecast care that is Medicare covered, related to an injury in the form of a “mini” Life Care Plan that could be used to satisfy the Centers for Medicare and Medicaid Services (CMS) Medicare Secondary Payer (MSP) requirements involving a Workers Compensation commutation settlement. The concept was quickly adopted by the Workers Compensation industry as the gold standard for meeting the requirement of future obligations to protect Medicare. When the first Workers Compensation Review Contractor (WCRC) was established in 2003 to evaluate Workers Compensation Medicare Set Asides (WCMSA), the “mini” Life Care Plans became the standard accepted methodology by CMS, introduced to them by the MSA industry.
Research and Analysis of the Accuracy/ Validity of Life Care Planning
In 2013 we conducted an analysis of 100 Medicare Set Asides (MSAs) submitted to CMS for review and approval and compared the CMS future care results to actual treatment rendered, two-year post settlement. Upon review of the medical records, we identified that 94 of the 100 claimants treated less frequently and received less prescription drugs than what was allocated by 30% or more. Of the remaining 6 claims, which closely aligned with the Medicare Set Asides forecasts, the common denominator was they each represented a catastrophic or chronic, progressive condition i.e. spinal cord injury, chronic obstructive pulmonary disease (COPD) due to an exposure and/ or debilitating rheumatoid arthritis. We could not ignore that the overwhelming majority of MSAs did not resemble the care forecasted using standard MSA methodology.
In 2014, we performed claimant interviews, medical record reviews and an analysis of seventeen Life Care Plans and compared the actual treatment rendered, ten-years post settlement, involving Medicare beneficiaries living in the Sarasota, Florida region. The results were a non-starter upon identifying that only one out of the seventeen beneficiaries interviewed knew they had a Life Care Plan. This single beneficiary did not have a copy of the Life Care Plan, and reportedly did not follow the medical recommendations or expend the medical settlement funds as intended to maximize his functional independence.
Following an exhaustive quest to validate Life Care Planning methodology with post settlement measurements, we concluded that no empirical evidence exists to support the methodology of Life Care Planning is valid. Members of the Life Care Planning community defend the lack of validation by stating that the practice itself defines a Life Care Plan as a “dynamic document”, a process characterized by constant change or activity, and therefore no claims are made as to the accuracy of the forecasts.
Using BIG data and Predictive Modeling to Forecast Medical Care
Care Bridge International hosts a data warehouse of over 1 billion medical claim transactions, over 16 million unique claims, including 2500 CMS reviewed and approved MSAs. Using predictive modeling, the company forecasts medical valuations for litigation, medical reserves and MSAs for Workers’ Compensation and liability bodily injury claims with a high degree of accuracy, within less than 10% margin of error. An actuarial review of the company’s data, methods and processes was given a credible endorsement in 2017.
Analytic-Powered Outcomes® vs. Life Care Planning methodology:
In comparing the approaches (as shown below) it is clear the use of big data provides a valid and reliable foundation from which to forecast medical care compared to Life Care Plans.
This Medical Forecast is based upon published standards of practice, comprehensive assessment, and research, and is validated using real claims data from our copyrighted, actuary-endorsed, Analytic-Powered Claims Database©, representative of over 16 Million injury claims from 43 states. The result is an organized concise plan for current and future needs with associated costs for individuals who have experienced an injury or have chronic health care needs. This Medical Forecast is specific to CONFIDENTIAL CLAIMANT and represents a preventive plan intended to minimize complications and maximize functional potential. Pricing of medical services is geographically specific. Data included in the preparation of this Medical Forecast includes 3,531 specific claimants who sustained a closed patella fracture since 2005.
About Deborah Watkins As the CEO of Care Bridge International, Deborah Watkins received the 2010 Oracle Titan Award and Gartner 1to1 CRM Silver Award for technology implementation. She has worked closely with industry leaders, including NCCI to produce “Medicare Set Asides and Workers Compensation” presented at the 2014 Annual Issues Symposium and September 2014, Research Brief. She has a Master of Science in Nursing and a Master’s in Healthcare Leadership (MBA/MPH) from Brown University and is a past board secretary for the National Association of Medicare Set Aside Professionals (NAMSAP). Watkins is an experienced clinician and insurance executive, having spent most of her career responsible for complex claims management, integrating technology and evidenced based clinical and technical processes. She was directly involved with the Centers for Medicare and Medicaid’s early pilot program for Medicare Advantage Plans, formerly Medicare + Choice.
About Care Bridge International
Using Big Data, Care Bridge International offers a technology-based solution to forecast medical treatment and costs for medical reserve setting, claim settlements, litigation, care coordination, Medicare set asides and dually eligible beneficiaries.